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|Year : 2011 | Volume
| Issue : 51 | Page : 113--121
Hearing loss prevention for carpenters: Part 1 - Using health communication and health promotion models to develop training that works
Carol Merry Stephenson1, Mark R Stephenson2,
1 National Institute for Occupational Safety and Health, Education and Information Division, 4676 Columbia Parkway, C-10, Cincinnati, OH 45226-1998, USA
2 National Institute for Occupational Safety and Health, Division of Applied Research and Technology, 4676 Columbia Parkway, C-27, Cincinnati, OH 45226-1998, USA
Carol Merry Stephenson
NIOSH- Taft Lab, 4676 Columbia Parkway, C-10, Cincinnati, OH 45226-1998
In phase 1 of a large multiyear effort, health communication and health promotion models were used to develop a comprehensive hearing loss prevention training program for carpenters. Additionally, a survey was designed to be used as an evaluation instrument. The models informed an iterative research process in which the authors used key informant interviews, focus groups, and early versions of the survey tool to identify critical issues expected to be relevant to the success of the hearing loss prevention training. Commonly held attitudes and beliefs associated with occupational noise exposure and hearing losses, as well as issues associated with the use or non-use of hearing protectors, were identified. The training program was then specifically constructed to positively shape attitudes, beliefs, and behavioral intentions associated with healthy hearing behaviors - especially those associated with appropriate hearing protector use. The goal was to directly address the key issues and overcome the barriers identified during the formative research phase. The survey was finalized using factor analysis methods and repeated pilot testing. It was designed to be used with the training as an evaluation tool and thus could indicate changes over time in attitudes, beliefs, and behavioral intentions regarding hearing loss prevention. Finally, the training program was fine tuned with industry participation so that its delivery would integrate seamlessly into the existing health and safety training provided to apprentice carpenters. In phase 2, reported elsewhere in this volume, the training program and the survey were tested through a demonstration project at two sites.
|How to cite this article:|
Stephenson CM, Stephenson MR. Hearing loss prevention for carpenters: Part 1 - Using health communication and health promotion models to develop training that works.Noise Health 2011;13:113-121
|How to cite this URL:|
Stephenson CM, Stephenson MR. Hearing loss prevention for carpenters: Part 1 - Using health communication and health promotion models to develop training that works. Noise Health [serial online] 2011 [cited 2020 Aug 8 ];13:113-121
Available from: http://www.noiseandhealth.org/text.asp?2011/13/51/113/77207
Occupational hearing loss
It has been argued that, "Preventing occupational hearing loss would do more to reduce the societal burden of hearing loss than preventing all other causes of ear disease combined. Because the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) began tracking and specifically recording occupational hearing loss on the OSHA Logs in 2004 (these reports are submitted by employers; Official logs of work related injuries and illnesses), it has been the leading or second-most commonly recorded occupational illness among American workers.  Obviously, applying control technologies to eliminate noise hazards or removing the worker from hazardous noise areas are optimal choices for preventing occupational hearing loss. In the absence of these controls, using hearing protection devices (HPDs) remains the best way to reduce workers' noise exposures and thereby prevent occupational noise-induced hearing loss (NIHL). However, getting workers to wear HPDs properly is not a straightforward task. In fact, it has been claimed that, "Failure to fit hearing protectors properly and to wear them consistently is probably the leading cause of occupational noise-induced hearing loss."  Indeed, it has been well documented that hearing protectors' real world attenuation bears little correlation with the Noise Reduction Ratings (NRRs) that are published on the devices' packaging. ,,, It has also been well documented that workers in many sectors, especially construction, commonly fail to wear hearing protection when and how they should.  However, there is good evidence that effective training can significantly increase HPD use. ,
The present study was designed to improve hearing loss prevention training for construction workers, specifically carpenters, by applying lessons learned from prior use of health communication and health promotion theories. These theories led investigators to fully explore and assess training content and delivery options designed to (a) encourage workers to develop positive attitudes and beliefs about hearing protectors and hearing protector use on the job and (b) promote strong behavioral intentions to use hearing protection when and how it should be worn. Put more simply, you can lead a person to hearing protectors, but how do you motivate him or her to wear them?
The answer to this question lies in developing evidence-based interventions that promote and support the proper use of hearing protection when other controls have not yet eliminated the noise hazard. If one examines the existing hearing conservation training programs, one finds that, in many cases, the training is singularly focused on the presentation of knowledge. OSHA specifies minimum content for hearing conservation training as, "…at least annually in the effects of noise; the purpose, advantages, and disadvantages of various types of hearing protectors; the selection, fit, and care of protectors; and the purpose and procedures of audiometric testing. The training program may be structured in any format, with different portions conducted by different individuals and at different times, as long as the required topics are covered." 
Obviously, educational materials must be factual and impart appropriate knowledge and skills. However, to be truly effective, the information should be presented within the context of an evidence-based training perspective. Successful hearing loss prevention training will positively impact hearing loss prevention behaviors on worksites. It is not enough simply to present workers with the facts associated with occupational hearing loss and expect them to change their attitudes, beliefs, and behaviors regarding the use of hearing protection. Knowledge and skill competency is a necessary, but not sufficient, factor leading to lasting behavior change. Addressing motivational aspects of behavior change is also required. 
For this effort, the authors chose to develop the content of the new training based on what has been learned from health communication theory and select HPMs. These theoretical substrates consider human behavioral dynamics and "provide a road map for studying problems, developing appropriate interventions, and evaluating their results. They… can inform the planner's thinking during all of these stages, offering insights that translate into stronger programs."  Because theory helps identify problems to target, mechanisms for change, and metrics to determine intervention effectiveness, interventions grounded in theory are more likely to succeed than those without a theoretical foundation.  The methods used in this study are grounded in a specific aspect of health communications theory and two HPMs.
Health communication theory: Message framing
Researchers and public health practitioners use findings from health communication research to improve persuasive messages targeting a myriad of health issues, from smoking to obesity. Much can be gained by applying lessons learned in this discipline to hearing conservation training programs. One such lesson is the need to carefully and precisely construct health and safety messages so that they influence group social norms, individual beliefs, and corresponding behaviors. Message "frame" is one important aspect of targeting messages that affects how people perceive a health threat. For this effort, the authors focused on applying what is known about message framing to carefully construct specific components of the training in terms of losses that may be suffered by ignoring hearing loss prevention or gains likely to be realized by adopting hearing healthy recommendations. Simply put, training can emphasize the consequences of a health behavior in terms of either the benefits associated with changing one's behavior or the harm associated with not changing one's behavior. Generally, the body of research in health communication suggests that gain-framed messages seem to better promote prevention behaviors (e.g., "wear hearing protection and keep your hearing and quality of life") and loss-framed messages are better at promoting detection behaviors (e.g., "If you don't take your yearly hearing test, you can lose your hearing and won't even realize it until it is too late.").
Myerowitz and Chaiken  conducted early, classic work with message framing for health issues and, subsequently, a rich body of literature has been amassed on the topic. The explanation for the loss or gain framing effect is that "loss framed" persuasion works when the behavior being promoted entails some "risk" to the person. In risky situations, people worry more about suffering losses than worry about gaining something and so they pay attention to loss messages and are more willing to act. Asking a noise-exposed person to take a hearing test can be psychologically risky. The test may force them to confront a hidden, potentially serious hearing problem. However, when the purpose of the communication is to encourage healthy people to act in ways that will prevent a health condition from developing sometime in the future, the situation is less risky because people know they are currently fine. Additionally, people believe they have some control over what they do to stay well. In these types of situations, the research results favor "gain" framing. For example, Rothman et al.  found that gain framing (e.g., "using sunscreen prevents cancer") resulted in more sunscreen usage than loss framing (e.g., "not using sunscreen doubles your risk of cancer").
We now know, from an additional decade of research, that other factors can sometimes mediate message framing effects, but for the purposes of this study, our investigation focused on applying loss and gain framing throughout the training in a consistent manner. Prevention activities were framed in terms of gains expected and detection activities were framed in terms of potential losses to hearing and quality of life.
Several studies have suggested that using health communication practices alone or within the theoretical framework of a HPM leads to the development of even more effective hearing conservation interventions. ,,,, Specifically, several HPMs predict behavior change by identifying factors that appear to be associated with workers' attitudes, beliefs, and behavioral intentions. One of the earliest and most parsimonious of these models, and one with a lengthy body of research supporting its validity, is the Health Belief Model (HBM). Initially described by Rosenstock and others in the 1970s,  the HBM suggests that behavioral responses to a health risk (such as noise-induced hearing loss) are strongly related to several measurable constructs:
Susceptibility: one's beliefs about one's vulnerability to a particular health risk.Seriousness: one's beliefs regarding the seriousness of the health issue if it were to be contracted; i.e., how seriously would the health issue affect one's quality of life.Benefits of taking action: how firmly one believes that he or she will benefit from the steps taken to protect oneself. This construct also includes beliefs regarding the effectiveness of the proposed protective measures.Barriers: one's beliefs regarding the barriers to adopting protective behaviors, and one's own ability to overcome those barriers.
The HBM predicts that individuals cognitively process these constructs in order to assess the consequences of taking action or doing nothing. Later, iterations of the model added that an understanding of "cues to action" and personal "self-efficacy" to perform the desired behavior were modifying factors in the HBM framework.
For example, construction workers may believe that:
They are susceptible to noise-induced hearing loss because of their noisy work tasks.Hearing loss is serious and would have a significant impact on their quality of life.Hearing protectors offer a practical benefit to preventing noise-induced hearing loss.They are capable of surmounting any barriers associated with wearing hearing protection.
However, if when they attempt to purchase hearing protection they feel unsure about their ability to select and fit the devices they find in a store, the process of seeking protection may cease. Multiple studies have shown that whether or not one chooses to respond to the risk of occupational hearing loss by wearing HPDs is strongly influenced by self-efficacy, i.e. the belief in one's ability to effectively select and use hearing protectors to prevent hearing loss. 
The HBM served as the backbone for this work. Other HPMs also proved relevant to this effort, and are briefly described in the methods section where they were applied.
Despite a significant body of research demonstrating the successful application of health communication practices and health promotion theories to various health issues, there has not been universal optimism that these efforts will effectively improve hearing conservation programs or the education and training materials used in such programs. Borchgrevink  suggested that health promotion is not effective when applied to hearing conservation. This conclusion appears to be based on the observation that hearing loss is still a common occupational illness, despite decades of improvements to hearing loss prevention programs. We believe that this conclusion is premature. HPMs and health communication practices can and should be employed to develop more effective training for preventing occupational hearing loss.
Given this background, this paper describes a portion of the National Institute for occupational Safety & Health (NIOSH) response to a request for assistance in developing an effective hearing loss prevention program for construction workers. This effort was designed to be just one aspect of a much larger series of NIOSH activities related to better understanding hearing loss prevention program needs for the entire construction industry. This particular study allowed NIOSH to conduct rigorous formative research, leading to the development of a model hearing loss prevention training program for carpenters. The carpenters' program, in turn, could serve as a springboard program for other construction trades. The program would be firmly grounded in health promotion theory. Additionally, health communication practices associated with message framing were applied.
Phase 1: Formative research
In phase one, NIOSH and the United Brotherhood of Carpenters and Joiners Health and Safety Fund worked together to collect baseline data associated with all aspects of a hearing conservation program. Relevant to this report, this entailed gathering baseline information regarding carpenters' existing attitudes, beliefs, and behavioral intentions about hearing conservation in general, and hearing protector use in particular. Initially, seven focus groups and nine key informant interviews were held over a span of 2 years at national, regional, and local conferences attended by journeymen carpenters and union officials. The focus groups were convenience samples drawn each time from conference attendees and typically consisted of 8-10 individuals meeting around a table in a breakout room at the conference. Discussions were facilitated by the NIOSH staff, and typically lasted about 1 h. Attendees were given a token item, such as a NIOSH pin, in exchange for their participation. Additionally, a total of 15 focus groups with carpenters, apprentices, and carpenter trainers, respectively, were held at three apprentice training centers located in the Midwest (St. Louis, Indianapolis, and Cincinnati), a training center in Phoenix, AZ, and a training center in Henderson, NV. Finally, four more focus groups were conducted with senior carpenter health and safety professionals, labor leaders, and industry managers in Palm Springs, CA, at a carpenter joint labor-management health and safety conference as well as at a national construction industry workshop held in conjunction with the National Safety Council. Each focus group was led by the same skilled moderator. Focus groups were conducted in accordance with standard procedures well described in the literature and the approach described by the Centers for Disease Control and Prevention. 
Key informant interviews were conducted one-on-one by the NIOSH staff and covered the same topics discussed in the focus groups. For both types of data collections (focus groups and interviews), an attempt was made to recruit, at each opportunity, a diverse sample of participants representing attendees from various parts of the country and an age range from the early 20s through the mid 60s. Attendees in all cases were predominantly male, reflecting the demographics of the trade. Saturation of themes, meaning no new themes emerged from additional data collections, was readily achieved within the 2 years.
Analysis of the data from the focus groups and key informant interviews soon suggested to the investigators that no single health promotion theory addressed all of the factors and themes emerging from the data that seemed related to hearing health in a construction workplace environment. Thus, four theories were combined to guide the development and evaluation of the training materials and the survey tool used in this study. This approach is not without precedent, as Witte  suggested that "Integrating elements of several models into an eclectic approach has proven to be successful in crafting a carefully framed message targeted to a specific audience, while still being able to address diverse stages of viewers' receptivity to the message."
As noted previously, the HBM served as our starting point. Attractive in its simplicity and in the ease with which its constructs of susceptibility, seriousness, benefits, and barriers could be operationalized through surveys, it was quite feasible to apply this model and assess the core beliefs central for hearing protector use. In this way, the HBM served as the backbone of our training program.
Additionally, the Theory of Reasoned Action, developed by Ajzen and Fishbein,  provided an understanding of the importance of gathering information about behavioral intentions. Research using the Theory of Reasoned Action has documented that behavior can successfully be predicted by surveying appropriate attitudes and then asking people to reveal their future behavioral intentions relevant to a health issue (e.g., Aherin, et al.  ). While the correlation between behavioral intentions and actual behavior is not perfect, and can vary due to a myriad of individual, environmental, and social factors, many studies have documented moderate to strong correlations.
A third model also influenced our approach to developing the new hearing loss prevention program for the construction industry. The HPM - developed by Nola J. Pender , and expanded by Bandura  - influenced subtle aspects of the structure and content of our training program. It also is compatible with, and perhaps derived from, the Health Belief Model and the Theory of Reasoned Action. The HPM is based on a number of theoretical propositions centered upon individual characteristics and experiences, behavior-specific thoughts and feelings, and behavioral outcomes. From the perspective of designing a hearing loss prevention training program, this model complements the HBM and Theory of Reasoned Action, and adds useful constructs stressing the importance of positive role models when encouraging a behavioral change and the value of asking people to make a public commitment to the promoted behavior.
Finally, our training program was designed to incorporate message framing informed by Prochaska and DiClemente's Transtheoretical Model, also known as the "Stages of change theory." , In this model, behavior change in individuals or groups progresses through a predictable and orderly series of stages (pre-contemplation, contemplation, preparation, action, maintenance). Processes of change (such as peer support) determine how people move from stage to stage. Persons also engage in decisional balance at each stage, weighing the pros and cons of changing behavior. Additionally, beliefs about ones' self-efficacy to perform desired health behaviors can strengthen one's resolve to adopt and maintain those behaviors. Within the research literature, there are studies both supporting and rejecting the transtheoretical model. Despite this inconsistency of results, the typical pattern of stages first reported by Prochaska and DiClemente provide a useful heuristic for the development of targeted health messages, and seemed to apply to themes derived from the qualitative data collected in phase 1. When applying the transtheoretical model, characteristics of individuals at each stage give insight into how training and communication messages should be framed for maximum impact. While research has suggested that not all individuals progress through the stages in precise order, the theory has considerable value in helping training developers or health communicators think about how they might phrase and present information. The model is summarized in detail by Prochaska et al. 
Phase 2: Development of the training program and the associated survey instrument
Using the framework from all these theories, data derived from carpenters in phase 1 guided the development of a carefully targeted training program based on a message framework that addressed the following constructs: (1) carpenters' perceived susceptibility to hearing loss, (2) carpenters' perceived severity of the consequences of hearing loss, especially with regard to quality of life, (3) perceived benefits of preventive action, primarily seek hearing tests to monitor one's own hearing and wearing hearing protection when and where appropriate, (4) perceived barriers to preventive actions, (5) self-efficacy to select, fit, and wear appropriate hearing protection, (6) social norms within construction work settings associated with hearing loss prevention (a component of safety climate), and (7) stated behavioral intentions to engage in recommended actions. By incorporating these constructs into the hearing conservation training, the authors hypothesized that it would be possible to positively influence the attitudes, beliefs, and behavioral intentions associated with hearing protector use among carpenters.
In order to evaluate the effectiveness of this training program, NIOSH also developed a survey tool designed to directly assess the targeted constructs presented within the training program. This instrument enabled researchers to quantify the extent to which the training influenced the attitudes, beliefs, and behavioral intentions associated with hearing loss prevention and hearing protector use.
Survey tool development
In a previous effort, NIOSH had developed and delivered a 61-item survey to over 800 construction workers in an effort to better understand construction workers attitudes and beliefs about hearing conservation. Details regarding the validity and reliability of the original survey questions, form A and form B equivalence, and the general procedures used to develop the survey are described by McDaniel.  However, a 61-item survey had proved to be too long for our purposes and, thus, additional analytic work including a detailed factor analysis performed on a random sample of 500 responses from carpenters shortened the instrument to 28 items that specifically addressed the individual constructs targeted in the training materials used in the present study. Superfluous questions that did not load on the constructs or that appeared to load across several constructs were eliminated. Alternate forms of the survey were prepared simply by randomizing the questions on form A and reframing some from a positive to a negative context. Cognitive testing was conducted on the reframed questions to ensure that they still targeted the same concepts as in the original framing. A multiple forms analysis was conducted with 25 subjects to confirm comparability of responses. In the final version of the instrument, a 5-point Likert scale was used to code participant responses. Thus, after each survey statement, participants were asked to mark whether they strongly agreed, agreed, neither agreed nor disagreed, disagreed, or strongly disagreed with the statement. Appendix A contains a list of all questions used in the final survey for both forms. Survey items are organized under the constructs to which they apply. When presented to the carpenter apprentices, the questions were randomized into form A and form B.
The focus groups and key informant interviews provided a rich qualitative data set that was used to carefully frame each aspect of the training with regard to gains and losses expected to be meaningful to this audience. Additionally, repeated testing of the draft training ensured that (1) the training content was sharply focused on the constructs embodied in the HBM, Theory of Reasoned Action, HPM, and transtheoretical model and (2) that the planned training content was cognitively appropriate to the audience and delivered incorporating relevant health communication principles. For example, focus groups provided information about barriers to HPD use encountered by carpenters, which clarified that most apprentice carpenters would be classified as contemplators or planners in the "stages of change," and explored possible strategies the training might employ to promote loss or gain perspectives with regard to quality of life issues associated with noise-induced hearing loss. Focus groups clearly had been conducted to saturation, i.e. until no new themes emerged by the final months of data collection or during pilot testing, particularly with regard to the identification of any new barriers.
As the materials were developed, additional focus groups and interviews were employed to review drafts of the training materials in order to conduct cognitive testing of the materials. This testing insured clarity of meaning, appropriateness of the literacy level of the training materials, ability of the materials to address barriers that had been identified, and adequacy of the skill components incorporated into the training. The training program incorporates numerous suggestions by subject matter experts, apprentices, carpenters, carpenter trainers, and supervisors.
The final training program consists of a 30-min PowerPoint presentation/interactive discussion led by an instructor and a skill mastery session. The multimedia product includes imbedded video segments that specifically address barriers and model appropriate hearing health behavior and that clearly demonstrate hearing protector-fitting skills. This instructional session is designed to be followed by hands-on workshop activities designed to help trainees master the skills needed to select and fit hearing protectors. The total time for training is designed to take about 45 min. This was purposeful in order to fit into a typical training period at the carpenter apprentice training centers. The training was also designed so that each of the constructs believed to influence behavioral intentions to use HPDs was addressed at least twice. In pilot testing, the training content demonstrated high face validity for apprentices and trainers. Notably, it is grounded in relevant examples drawn from a task-based exposure assessment of carpentry tasks collected by NIOSH and reported elsewhere.  Each task's potential for causing noise-induced hearing loss is stressed in the training.
To ensure that the training is engaging, a multimedia approach was used, which includes short videos embedded within the PowerPoint presentation. One of these videos addresses susceptibility to hearing loss, social norms, and barriers to HPD use. A second video addresses consequences of inaction and self-efficacy. Additional video shorts detail specific skills related to fitting all types of HPDs. Most of the training videos were shot primarily at carpenter apprentice training centers using apprentices and their trainers. Incorporating carpenter apprentice peers and respected older carpenters into the training materials established training legitimacy and provided positive role models.
Because focus group and key informant interview responses indicated that principle reasons for not using HPDs were consistent with the themes identified in prior NIOSH investigations (the five C's: comfort, convenience, communication [i.e., perceived inability to hear speech and other important sounds such as warning signals], cost, and the safety culture/climate  ), the hearing protector fitting workshop portion of the training was specifically designed to guide the instructor to address those barriers.
To summarize this report, NIOSH established a program of research investigating best practices for hearing loss prevention programs within the construction industry. As part of that effort, NIOSH conducted a health hazard evaluation with carpenters, which documented extensive occupational hearing loss among journeymen in this trade. NIOSH then gathered extensive formative data leading to the development of a comprehensive 45-min-long hearing loss prevention training program. In parallel, a survey tool was developed that directly assesses the attitudes, beliefs, and behavioral intentions relevant to the success of using the training. The survey tool is designed to quantify changes in the attitudes, beliefs, social norms related to hearing protector use, and behavioral intentions after training. With regards social norms, the survey specifically targets whether or not coworkers and managers usually wore HPDs when working in noise.
Although it may seem obvious that effective training should be framed to take into consideration content derived from formative research, such as that used in this study, this is not always feasible. However, taking the time to conduct at least a basic needs assessment and gather formative information about existing concerns from your target audience will ensure that important constructs are identified and incorporated into new training. For example, while a general construct like "need to hear sounds" was expected to surface for construction workers associated with hearing protector use, the specifics related to this barrier can vary widely between trades. For carpenters, tool noise was associated with tool quality and power and, thus, it was important to educate carpenters about the value of buy-quiet as part of a hearing loss prevention program. Similarly, carpenters do not generally associate hammering with hazardous noise. Thus, teaching about the significantly increased risks for hearing loss from such impulsive types of noises was an important part of our training program. Employing a methodical approach for identifying workers' pre-existing attitudes, beliefs, and behavioral intentions is critical to the process of developing effective hearing loss prevention training and, ultimately, evaluating the effectiveness of that program.
When control technologies are not possible or feasible, using hearing protectors is the only option for reducing noise exposure. Education and training programs that simply impart factual information about noise and hearing loss are unlikely to substantially motivate workers to actually use hearing protectors when and how they should. Health communication theory and numerous HPMs argue that education and training must be designed to positively influence behavioral intentions to perform an activity (e.g., use hearing protectors). Without first establishing this behavioral intention, the actual behavior is unlikely to follow. Likewise, behavioral intentions are influenced by several antecedents. For example, in order to foster behavioral intentions to use hearing protectors, education and training must ensure that workers understand their susceptibility to hearing loss because of the tasks they perform, the severity of hearing loss as a quality of life handicap, and the benefits of preventive actions, including when and how to wear hearing protectors. Training must focus on the specific barriers to hearing protector use, voiced by the target audience, and also ensure mastery of any needed skills such that a high degree of self-efficacy is felt by the participants on completion of training.
The present study employed a series of focus groups to understand carpenters typical attitudes, beliefs, and behavioral intentions related to occupational hearing loss. Results of these focus groups were used both to develop a hearing conservation training program as well as to develop a survey tool designed to measure these attitudes, beliefs, and behavioral intentions. The resulting training program was field tested in two demonstration projects, as reported in part 2 of this report, within this issue. In general, generic educational and training materials are likely to provide only "hit or miss" content relevant to the needs of a given audience. Based on the present results, these authors concur with prior studies  and recommend that hearing conservation education and training programs be specifically tailored to sharply focus on variables known to affect the target audiences' attitudes and beliefs, particularly with regard to barriers preventing effective use of noise controls and hearing protection.
The authors are deeply indebted to the United Brotherhood of Carpenters and Joiners of North America (UBC) for their support through every phase of this effort. We would particularly like to express our appreciation to Mr. Joseph Durst, then the UBC Director of Health and Safety, and to UBC Master Trainers Cliff Valarose and Bronco Hollis for their assistance in coordinating focus group sessions. This effort would not have been possible without the support of Mr. Art Galae, Director, and the staff of the UBC Joint Apprenticeship Training Center, Monroe, OH, as well as Mr. Bill Smith, Director, and the staff of the UBC Joint Apprenticeship Training Center, Indianapolis, IN. Numerous other union officials and journeymen carpenters from throughout the United States provided input or review during this project.
Appendix 1: Final Apprentice Carpenter Survey: Content Areas and Questions
Perceived susceptibility to hearing loss
1. I think I can work around loud noise without it hurting my hearing. 
2. I believe exposure to loud noise can hurt my hearing. 
1. I don't think I have to wear hearing protectors every time I am working in loud noise. 
2. If I don't protect my ears, loud noise can damage my hearing. 
Perceived severity of consequences of hearing loss
1. Losing part of my hearing would make it harder for people to talk to me. 
2. I don't think it would be such a big handicap to lose part of my hearing because I work around a lot of noise. 
1. Losing part of my hearing would not make it hard for people to talk to me. 
2. It would not bother me if I lost part of my hearing because of the noise I work around. 
Perceived benefits of preventive action
1. I am convinced I can prevent hearing loss by wearing hearing protectors whenever I work in loud noise. 
2. I can't protect my hearing unless I wear hearing protectors around loud noise. 
3. If I really want to keep my hearing, it is important for me to wear hearing protectors every time I am around loud noise. 
1. If I wear hearing protection, I can protect my hearing from loud noise. 
2. I won't lose my hearing if I wear hearing protectors when I work around loud noise. 
3. I need to wear hearing protectors every time I'm around loud noise if I really want to keep my hearing. 
Perceived barriers to preventive action: comfort
1. Earmuffs are too hot or heavy to wear on my job. 
2. Earmuffs put too much pressure on my ears to be comfortable. 
3. Earplugs can be comfortable to wear if they are fit right. 
1. Earplugs are uncomfortable to wear, even when they are fit right. 
2. I can find an earmuff that is not too heavy or hot for me to wear. 
3. If I need to use an earmuff I can get one that can be adjusted so it won't put too much pressure on my ears. 
Perceived barriers to preventive action: Muffle important sounds
1. It is hard to hear warning signals like back-up beeps if I am wearing hearing protectors. 
2. Wearing hearing protectors does not stop me from hearing important sounds my tools or machinery make. 
1. Even when I am wearing hearing protectors, I can still hear back-up beeps or other warning signals. 
2. I can't hear problems with my tools or machinery if I wear hearing protectors. 
Perceived barriers to preventive action: Communication
1. I can't wear hearing protectors because I need to hear people talk to me while I am working. 
2. I can understand speech well enough to do my job while I am wearing hearing protectors. 
3. Even when it's not noisy, sometimes it's hard for me to hear when people are talking to me. 
1. I can still hear people talking to me while I do my job, even when I am wearing my hearing protectors. 
2. I can't hear speech well enough to do my job if I am wearing hearing protectors. 
3. Even when it's quiet, sometimes I have trouble hearing what people are saying to me. 
Perceived barriers to preventive action: Convenience/availability
1. Where I work, hearing protectors are readily available for me to use. 
2. It is not convenient for me to get hearing protectors to use at work. 
3. At work, I can choose from several different hearing protectors to find one I can use. 
4. Hearing protectors aren't too expensive for me to buy. 
1. Hearing protectors are not readily available for me to use where I work. 
2. It is convenient for me to get hearing protectors to use at work. 
3. I can't find a hearing protector I like to use because there's not a big enough variety to choose from where I work. 
4. Hearing protectors are too expensive for me to buy. 
1. I do not intend to wear hearing protectors when I am around loud tools or equipment. 
2 I usually wear hearing protectors whenever I am working around loud noise or equipment. 
3. If I had a hearing protector with me, I probably would wear it every time I was around noise that was loud enough to hurt my hearing. 
1. I intend to wear hearing protectors when I am around loud tools or equipment. 
2. I usually don't wear hearing protectors while I'm working around loud noise or equipment. 
3. Even if I had one with me, I probably wouldn't wear a hearing protector every time I was around noise that was loud enough to hurt my hearing. 
1. My coworkers usually wear hearing protectors when they work in hazardous noise. 
2. My coworkers don't usually wear hearing protectors when they need to work in noisy areas. 
1. My coworkers don't usually wear hearing protectors when they work in hazardous noise. 
2. My coworkers usually wear hearing protectors when they need to work in noisy areas. 
1. I can't always tell when I need to use hearing protectors. 
2. I believe I know how to fit and wear hearing protectors. 
3. I can tell when an earplug or earmuff needs to be replaced. 
4. If coworkers asked me, I could show them how to fit and wear hearing protectors the right way. 
1. I know when I should use hearing protectors. 
2. I'm not sure I know how to fit and wear hearing protectors. 
3. I can't always tell when an earplug or earmuff needs replacing. 
4. I don't think I could show a coworker the right way to fit and wear hearing protectors. 
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